Claremont | 08 9384 6855 Jandakot | 08 9414 1470

Coronavirus (COVID-19) Questionnaire

COVID-19 Questionnaire

    If you have been exposed to coronavirus (COVID-19), you may spread the virus to your Paediatric Dentist or Orthodontist, our team, or other patients/parents/visitors to the Practice. Therefore, prior to each appointment, we will be asking you to confirm answers to the following questions to reduce the chances of transmission of COVID-19 in our Practice. If you answer Yes to any of the Health Questions below, you will be asked to reschedule your next dental appointment to a later date.

    Patient Details

    Next Appointment Date:

    Next Appointment Time:

    COVID-19 Screening Questions

    New COVID-19 protocols have been released by the WA Government in relation to a high caseload environment which including updates to the definition of a close contact and testing and isolation protocols.

    Please check the latest health advice and restrictions detailed on the WA Government’s website prior to responding to these appointment screening questions.

    In relation to ANY member of the patient's family/household and/or accompanying person attending the next appointment:

    Have you been to a COVID-19 exposure site in the last 14 days?


    Have you tested positive for COVID-19 and currently subject to self-isolation/testing restrictions?


    Are you a ‘close contact’ (asymptomatic or symptomatic) and currently subject to self-isolation/testing restrictions?


    Do you have COVID-19 symptoms but are not considered a ‘close contact’?


    Have you taken a PCR or RAT in the last 14 days which has delivered a positive test result?


    Have you returned from travel overseas or interstate in the last 14 days?


    If you answered ‘yes’ to any of the above questions, please provide more details below:

    Informed consent for dental treatment during the COVID-19 pandemic

    I understand that COVID-19 has a long incubation period during which time carriers of the virus may show no symptoms and still be highly contagious. It may not be possible to determine whether someone has COVID-19 or not given current limits in virus testing. I understand that there is therefore a risk that a person attending First Smiles may be infected with COVID-19 and expose either me, my child or an accompanying person to COVID-19.

    In light of the known risks in relation to contracting COVID-19, I consent to me or my child (as relevant) receiving dental treatment at First Smiles during the COVID-19 pandemic period.

    We thank you for your understanding in implementing these measures which are designed to preserve your health and safety, that of our other patients and our team, and limit the community transmission of COVID-19. If you have any questions in relation to this COVID-19 Questionnaire and the protocols in place in our office, please email or call us on 9367 9277.

    We look forward to seeing you soon.